INCIDENT REPORT FORM

FOR SITUATIONS INVOLVING KIDS HOPE VOLUNTEERS

This form is to be used to notify Kids Hope of any incident involving injury or harm to a Mentor, or damage to a Mentor’s personal property while on school premises. It is also used to report any concerns about the conduct or behaviour of a Kids Hope volunteer. The school’s incident reporting procedures must be completed first, after which this form should be submitted within 24 hours.

Full Name:

Role: eg. Mentor, Coordinator, chaplain etc

Date

Date of Incident (if different to date above)

School name:

Church name:

Nature of the incident (accident, injury, behaviour or concern) including times, date, location, what happened and who was involved:

Details of injuries to the Mentor and any medical attention received:

Details of any damage to personal belongings:

Any treatment or action taken (by the school or others):

Date of report given to Principal/School Leader:

Date of notification to Coordinator/Church Leader:

Contact Information